Synchronous Diagnosis of Multiple Myeloma, Breast Cancer, and Monoclonal B-Cell Lymphocytosis on Initial Presentation

Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2016, Article ID 7953745, 4 pages http://dx.doi.org/10.1155/2016/7953745 Case Report Synchronous Diagnosis of Multiple Myeloma, Breast Cancer, and Monoclonal B-Cell Lymphocytosis on Initial Presentation A. Vennepureddy,1 V. Motilal Nehru,1 Y. Liu,2 F. Mohammad,3 andJ.P.Atallah3 1 Department of Internal Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, USA 2Department of Pathology, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, USA 3Division of Hematology and Oncology, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, USA Correspondence should be addressed to A. Vennepureddy; [email protected] Received 20 December 2015; Accepted 24 April 2016 Academic Editor: Su Ming Tan Copyright © 2016 A. Vennepureddy et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The cooccurrence of more than one oncologic illness in a patient can present a diagnostic challenge. Here we report an unusual case of concomitant existence of multiple myeloma, breast cancer, and monoclonal B-cell lymphocytosis on initial presentation. The challenge was to accurately diagnose each disease and stage in order to maximize the therapeutic regimen to achieve cure/remission. Successful management of the patient and increased life expectancy can be achieved by multidisciplinary management and patient- oriented approach in multiple primary malignant synchronous tumors. 1. Introduction different patterns of MPMs should be considered. Thera- peutically, a multidisciplinary and patient-oriented approach Multiple primary malignant tumors (MPMTs) are rarely should be considered. observed in clinical practice; however, certain fundamental factors for the potential etiology have been described in the literature, including the environment and behavior (tobacco, 2. Case Report occupation, pollution, and ultraviolet light), genetic predis- A 77-year-old female with history of hypertension, diabetes position (Li-Fraumeni or Beckwith-Wiedemann syndromes), mellitus type II, dyslipidemia, and chronic kidney disease previous medical treatment (radiotherapy or chemotherapy), and complex interaction between all these factors [1]. The stageIIpresentedtoourhospitalafterafallinitiallysuspected association between varying cancer types can be classified to be secondary to mechanical factors without any loss of into two categories, which are dependent on the timing of consciousness. Her lab tests on admission were found to be their discovery. An American review stated that the tumors as follows: hemoglobin of 10.8 g/dL (baseline was 12.5 g/dL) with red blood cell indices within normal limits, white blood are synchronous when the cancers occur at the same time 9 cell count of 9.8 × 10 cells/L with absolute lymphocyte or within 2 months of each other, whereas metachronous 9 tumors occur when the cancers follow in sequence more count of 1.4 × 10 cells/L, absolute granulocyte count of 9 than 2 months apart [2]. The majority of MPMTs that occur 7. 8 × 10 cells/L, and normal platelets. Her serum creatinine in multiple organs are metachronous, while the presence of was 2.01 (baseline was 1.03) with a GFR of 29 and normal synchronous lesions is less common, and in accordance with serum electrolytes. The patient’s initial trauma workup and the behavior of malignancy lesions, these tumors are more physical exam revealed a palpable mass in the upper outer frequent with aging. quadrantoftheleftbreastandmultiplelyticlesionsonC2 This distinction implies important diagnostic and ther- and C5 vertebral bodies and T2 spinous process on the apeutic challenges. From a diagnostic point of view the computerized tomography (CT) scan. Subsequent magnetic 2 Case Reports in Oncological Medicine (a) (b) (c) (d) Figure 1: Colloid carcinoma of the breast. This invasive ducal carcinoma exhibits dominant mucin production and tumor cells are arranged in clusters and nests, floating in pools of extracellular mucin (a). Tumor cells are uniform in size and shape with hyperchromatic nuclei without prominent nucleoli and mitosis (b). PR (c) and ER (d) are positive in tumor cells. [(a) H&E, ×100; (b) H&E, ×400; (c) IHC, ×100; (d) IHC, ×100.] Kappa Lambda CD138 Cytokeratin (a) (b) Figure 2: Photomicrographs from femur bone biopsy (a) and bone marrow clot preparation (b) showing a monomorphic population of plasma cells intermixed with few small lymphocytes and other hematopoietic cells in the bone marrow. The plasma cells show mature cytological features with strong CD138 reactivity and restriction for kappa light chain. No morphologic evidence of carcinoma is identified in both specimens and staining with cytokeratin marker is negative. [(a) H&E, ×100; (b) H&E, ×400.] resonance imaging (MRI) noncontrast of the brain and cer- was done by serum and urine electrophoresis, serum and vical spine exhibited multiple focal lesions of the calvarium, urine immunofixation, and free light chain ratio. The results clivus, C2 and C5 vertebral bodies, and T1 spinous process revealed abnormal IgA kappa monoclonal protein with ele- and cord compression of C3-C4, C4-C5, C5-C6, and C6-C7 vated free light chain ratio. The patient’s subsequent bone suggestive of metastatic disease. The patient was started on marrow biopsy confirmed the diagnosis of MM but also dexamethasone while undergoing malignancy workup. She revealed a minute monoclonal B-cell population with typi- then underwent a nuclear medicine bone scan of the whole cal chronic lymphocytic leukemia (CLL)/small lymphocytic body which showed multiple bony abnormalities in the left lymphoma (SLL) phenotype confirmed via flow cytometry femoral shaft, left acetabulum, L1, L2, and multiple bilateral (Figure 2). ribs consistent with metastatic disease. The patient improved significantly with the supportive The patient’s mammogram and left breast ultrasound treatment and was discharged from the hospital with outpa- showed a 7.5 × 3.7 × 7.8 cm heterogeneous irregularly shaped tient follow-up. The patient was then started on REVLIMID mass at the 2:00 position, 15 cm from the nipple on the and Decadron for MM and pertuzumab, trastuzumab, and upper outer quadrant of the left breast. Subsequent biopsy letrozole for invasive ductal carcinoma of the breast. She ofthemassrevealedaninvasivewelldifferentiatedductal underwent positron emission tomography (PET-CT) as part carcinoma with mucinous features (colloid carcinoma) (Fig- of the initial treatment workup as well as for determining ure 1). The breast cancer proved to be triple positive for the appropriate site for bone biopsy to differentiate between estrogen, progesterone receptors, and HER2 via immunohis- metastatic breast cancer and MM as MM lesions usually tochemistry and fluorescence in situ hybridization testing. do not light up on the bone scan. The PET-CT revealed a The lytic lesions on bone scan were initially suspected tobe fluorodeoxyglucose (FDG) avid 4.3 × 5.1 cm partially calcified of metastatic breast cancer. leftbreastmass(SUV3.2)aswellasincreaseduptake(SUV The combination of acute kidney injury, normocytic 4.3) in the 5.3 × 4.3 cm lytic lesion of the right distal femur. normochromic anemia, and multiple bony lesions was sus- The right femur and left pubic bone were biopsied which pected of being multiple myeloma (MM) and its workup showed only monomorphic population of plasmacytoid cells Case Reports in Oncological Medicine 3 consistent with plasma cell neoplasm with no evidence of 4. Conclusion metastatic breast cancer (Figure 2). The patient is currently continuing the neoadjuvant In summary, here we presented a case of synchronous diagno- chemotherapy with pertuzumab, trastuzumab, and letrozole sis of MM, breast cancer, and monoclonal B-cell lymphocyto- while awaiting surgical evaluation for the triple positive sis on initial presentation. The diagnosis of dual malignancy localized left breast cancer and REVLIMID and Decadron for in a patient at the time of the first presentation is rare. We symptomatic multiple myeloma. She is also being monitored initially suspected the lytic lesions on bone scan could be for the progression of the CLL/SLL clone. from metastatic breast cancer but were found out to be only localized breast cancer with pure myelomatous involvement Synchronous diagnosis of two different primaries is very of bony lesions. This made the patient undergo mastectomy important as the management of these coexisting malignan- alongwithcontinuationofneoadjuvantchemotherapy.The cies is different. In our case report, we initially thought the patient also needs to be monitored for any development of lytic lesions could be from metastatic breast cancer which CLL from monoclonal B-cell lymphocytosis. Recognizing in turn proved to be pure myelomatous involvement of both malignancies at the time of presentation and before bone and no signs of metastases from breast cancer which initiation of treatment is crucial since the management of changed the management and made the patient undergo these coexisting malignancies is different. mastectomy. This patient should also be monitored for any In conclusion, successful patient’s management and evidence of development of CLL as we found monoclonal B- increased life expectancy can be achieved by multidisci- cell population with typical CLL/SLL

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